Functional Impairment as a Predictor of Depressive Symptomatology: The Role of Race, Religiosity, and Social Support

Cummings, Sherry M., Neff, James Alan, Husaini, Baqar A., Health and Social Work

Depression constitutes a major and growing health problem for older adults. Depressive symptoms are considered to be the most common mental health problem in later life and afflict up to 20 percent of those age 65 and older (Butler, Lewis, & Sunderland, 1998). Although levels of depression are highest among elderly people who are institutionalized, approximately 15 percent of community-dwelling elderly people suffer from depressive symptoms (National Institutes of Health, 1991). Some studies indicate that up to 30 percent of noninstitutionalized elderly people report significant depressive symptomatology (Fry, 1993).

If not treated, depressive symptoms can have a variety of negative outcomes for elderly individuals and for the community. Depressive symptoms complicate the treatment of physical illness, increase the risk of developing new illnesses and of mortality, and result in the increased use of health care resources independent of medical illness severity (Katrona, 1994; Williamson & Schulz, 1995).

Functional impairment and chronic illnesses also become increasingly prevalent with advancing age. In 1995 more than one-third (37.2 percent) of people age 65 and older reported difficulties in performing everyday activities of living because of chronic conditions (Administration on Aging, 1998). These chronic and disabling conditions affect not only their physical functioning, but also their emotional well-being. Repeated studies have demonstrated a relationship between functional impairment and levels of depression in community-dwelling elderly people (Djernes, Gulmann, Abelskov, Juul-Nielsen, & Sorensen, 1998; Pennix, Leveille, Ferrucci, van Eijk, & Guralnik, 1999). Impairment in instrumental activities of daily living (IADLs), such as shopping, meal preparation, and housekeeping, and in activities of daily living (ADLs), such as bathing, eating, dressing, and using the toilet, have been associated with higher levels of depressive symptoms (Valvanne, Juva, Erkinjuntti, & Tilvis, 1996). Alexopoulos et al. ( 1996) found that patient-reported disability; especially impairment in IADLs, was associated with severity of depression among elderly people and that this relationship remained even after controlling for the severity of medical illnesses.

Depressive symptomatology may also substantially influence the degree of impairment experienced. In one study of high users of health care services, a decrease in depression levels was accompanied by approximately a 50 percent reduction in the number of disability days (Von Korff, Ormel, Katon, & Lin, 1992). Djernes et al. (1998) also found a strong correlation between depression and impaired ADL functioning among older people and a significant improvement in functional ability following treatment of the depression.

Any discussion of functional impairment and depressive symptoms must contain an acknowledgement that the direction of causation is subject to debate. Although many studies appear to regard functional impairment as a cause of depressive symptoms, the relationship maybe more complex, perhaps even reciprocal. Thus, some researchers suggest that a decline in functional impairment presents chronic stress to elderly individuals that may provoke a depressive response. The depressive symptomatology may then result in higher levels of disability (Kempen, van Sonderen, & Ormel, 1999).

FUNCTIONAL IMPAIRMENT AND DEPRESSION: A COMPARISON OF AFRICAN AMERICAN AND WHITE ELDERLY PEOPLE

Lifelong exposure to health hazards, economic disadvantage, and limited access to health care place African American elderly people at greater risk of functional impairment and chronic illness. African Americans are twice as likely as white people to have chronic diseases. In addition, these chronic conditions more seriously limit the activity level of African Americans (Johnson, Gibson, & Luckey, 1990). Black men have 60 percent more restricted-activity days than white men, and black women experience 33 percent more days of restriction than white women. …

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